State of Illinois Certificate of Child Health Examination

FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 12/2011

Please correct the errors described below.

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Street/ City/ Zip Code

IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a  specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication.

Vaccine / Dose: DTP or DTaP

Vaccine / Dose: Tdap; Td or Pediatric DT (Select specific type)

Vaccine / Dose: Polio (Select specific type)

Vaccine / Dose: Hib Haemophilus influenza type b

Vaccine / Dose: Hepatitis B (HB)

Vaccine / Dose: Varicella (Chickenpox)

Vaccine / Dose: MMR Combined Measles Mumps. Rubella

Vaccine / Dose: Single Antigen Vaccines

Vaccine / Dose: Pneumococcal Conjugate

Vaccine / Dose: Other/Specify Meningococcal, Hepatitis A, HPV, Influenza

Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates to the above immunization history section, put your initials by date(s) and sign here.)

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

ALTERNATIVE PROOF OF IMMUNITY

1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.)

2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below is verifying that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Lab Results

    Please upload a file

    VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN

    Code:

    • P = Pass
    • F = Fail
    • U = Unable to test
    • R = Referred
    • G/C = Glasses/Contacts

    VISION

    HEARING

    (To add new entries, please click "Add new row")

    Add new row

    HEALTH HISTORY

    TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER

    *If yes, refer to local health department.

    *If yes, refer to local health department.

    Information may be shared with appropriate personnel for health and educational purposes.

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

    PHYSICAL EXAMINATION REQUIREMENTS

    Entire section below to be completed by MD/DO/APN/PA

    DIABETES SCREENING (NOT REQUIRED FOR DAY CARE)

    LEAD RISK QUESTIONNAIRE

    Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.)

    TB SKIN OR BLOOD TEST

    LAB TESTS (Recommended)

    Hemoglobin or Hematocrit

    Urinalysis

    Sickle Cell (when indicated)

    Developmental Screening Tool

    SYSTEM REVIEW

    Skin

    Ears

    Eyes

    Nose

    Throat

    Mouth/Dental

    Cardiovascular/HTN

    Respiratory

    Endocrine

    Gastrointestinal

    Genito-Urinary

    Neurological

    Musculoskeletal

    Spinal Exam

    Nutritional status

    Mental Health

    MENTAL HEALTH/OTHER

    On the basis of the examination on this day, I approve this child’s participation in:

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

    (MD,DO, APN, PA)

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